Metabolic Rx Intake Form Patient Name* First NameLast Name Patient Gender* Please Select Male Female Other Patient E-mail* example@example.com Phone Number Please enter a valid phone number. Patient Height (inches)* Patient Weight* What are your weight loss goals?* Patient Medical History Please list any drug allergies Have you ever had (Please check all that apply) AnemiaArthritisGoutEmotional DisorderFainting SpellsHeart DiseaseRheumatic FeverDigestive ProblemsUlcer DiseaseKidney DiseaseSleep ApneaThyroid ProblemsVenereal DiseaseBleeding DisordersEmphysemaAsthmaCancerDiabetesEpilepsy SeizuresGallstonesHeart AttackHigh Blood PressureUlcerative ColitisHepatitisLiver DiseaseUse a C-PAP machineTuberculosisNeurological DisordersLung DiseaseOther If you selected "other" please specify below Please list your Current Medications Healthy & Unhealthy Habits Exercise Never1-2 days3-4 days5+ days Eating following a diet I have a loose dietI have a strict dietI don't have a diet plan Alcohol Consumption I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day Caffeine Consumption I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day Do you smoke? No0-1 pack/day1-2 packs/day2+ packs/day Include other comments regarding your Medical History Submit Should be Empty:
